Abbreviations
Unacceptable Abbreviations
By the early 2000s, health practitioners were witnessing a high volume of errors in interpretation of medical abbreviations and symbols. In 2005, in an effort to reduce these errors, the Joint Commission began to require its member hospitals and outpatient centers to avoid the use of certain abbreviations that were previously acceptable. (The Joint Commission is the foremost health care standards–setting body in the United States.) For example, the abbreviation “qd” once was commonly used, but today, you must write out the word daily. Unfortunately, you still may see these older, ambiguous abbreviations and symbols in clinical records or in use by practitioners who refuse to make changes necessary for patient safety.
The following table lists terms that have been noted to cause errors in interpretation or appear on the Joint Commission "Do Not Use" list. They should be written out completely to prevent medical errors. (For the complete list of “do not use” medical abbreviations, including any updates, see the Joint Commission’s website at jointcommission.org.) Your office should have a list of approved abbreviations for use in patient records and other documents.
If you are reading a medical order and have even a slight concern about what you are reading, verify the order with the prescribing physician.
Acceptable Abbreviations
The following abbreviations are still considered acceptable and frequently used in charting.
- Prescriptions:
- ac = before eating
- Ad lib = as desired
- B.I.D. = twice a day
- g = grams
- gr = grains
- mcg = micrograms
- mL or ml = milliliters
- p.o. = by mouth
- pc = after eating
- prn = as needed
- Q.I.D. = four times a day
- STAT = immediately
- T or Tbs = tablespoon
- t or tsp = teaspoon
- T.I.D. = three times a day
- Chemistry:
- Ca = calcium
- Fe = iron
- H2O = water
- K = potassium
- Na = sodium
- NS = normal saline
- Disease:
- ADD = attention deficit disorder
- ADHD = attention deficit hyperactivity disorder
- AIDS = auto immune deficiency syndrome
- ALS = amyotrophic lateral sclerosis (commonly known as Lou Gehrig’s disease)
- ARDS = adult respiratory distress syndrome
- ASHD = arteriosclerotic heart disease
- BP = blood pressure
- BPH = benign prostatic hypertrophy
- CA = cancer
- CAD = coronary artery disease
- CHF = congestive heart failure
- COPD = chronic obstructive pulmonary disease
- CVA = cerebral vascular attack
- DM = diabetes mellitus
- GC = gonorrhea
- GERD = gastroesophageal reflux disease
- HTN = hypertension
- IBS = irritable bowel syndrome
- IDDM = insulin-dependent diabetes mellitus
- MI = myocardial infarction
- MR = mental retardation
- MS = multiple sclerosis
- MVP = mitral valve prolapse
- NIDDM = non-insulin-dependent diabetes mellitus
- PAT = paroxysmal atrial tachycardia
- PID = pelvic inflammatory disease
- PTSD = post-traumatic stress disorder
- PUD = peptic ulcer disease
- RA = rheumatoid arthritis
- RDS = respiratory distress syndrome
- SOB = shortness of breath
- STD = sexually transmitted disease
- TAH = total abdominal hysterectomy
- TIA = transient ischemic attack
- TURP = transurethral resection of prostate
- URI = upper respiratory infection
- UTI = urinary tract infection
- VD = venereal disease
- VSD = ventricular septal defect
- Procedures and Labs:
- ABG = arterial blood gas
- BS = blood sugar
- CABG = coronary artery bypass graft
- CBC = complete blood count
- CK = creatinine kinase
- CPR = cardiopulmonary resuscitation
- CT/CAT scan = computer tomography diagnostic procedure
- D&C = dilation and curettage
- EKG/ECG = electrocardiogram
- ESR = sedimentation rate
- ESWL = extracorporeal shock wave lithotripsy
- FBS = fasting blood sugar
- FHT = fetal heart tones
- HCT = hematocrit
- Hct/hgb = hematocrit and hemoglobin
- Hgb A1c = glycosylated hemoglobin
- I&D = incision and drainage
- IVP = intravenous pyelogram
- KUB = x-ray of kidney, ureter, and bladder
- LP = lumbar puncture
- MRI = magnetic resonance imaging
- PE = physical exam
- PT = protime
- PTT = partial thromboplastin time
- ROM = range of motion
- T&A = tonsillectomy and adenoidectomy
- VS = vital signs
- WNL = within normal limits
- Clinical Records:
- Bx = biopsy
- CNS = central nervous system
- CSF = cerebral spinal fluid
- Dx = diagnosis
- EDC = estimated date of confinement
- ENT = ear, nose, and throat
- FUO = fever of undetermined origin
- GI = gastrointestinal
- HEENT = head, eyes, ears, nose, and throat
- I&O = intake and output
- IM = intramuscular
- IV = intravenous
- LMP = first day of last menstrual period
- LOC = level of consciousness
- N&V = nausea and vomiting
- NKA = no known allergies
- OB = obstetrics
- Ob/gyn = obstetrics and gynecology
- OT = occupational therapy
- OTC = over the counter
- PERRLA = pupils equal round reactive to light and accommodation
- PT = physical therapy
- Px = physical
- Rx = prescription
- subQ or subC = subcutaneously (the Joint Commission no longer approves SQ or SC)
- Sx = symptoms
- Tx = treatment
- VS = vital signs